What is the approach to managing ear pain in the Emergency Department (ED)?

Approach to Ear Pain in the Emergency Department

The management of ear pain in the emergency department should begin with prompt pain assessment and appropriate analgesic treatment based on pain severity, followed by diagnosis and targeted therapy for the underlying cause. 1

Initial Assessment and Pain Management

Pain Control (First Priority)

• Assess pain severity using appropriate scales (faces, Oucher, or visual analog scales) 1
• Implement analgesic treatment immediately, without waiting for diagnosis 1
• Pain medication options based on severity:
  • Mild to moderate pain: Acetaminophen or NSAIDs (ibuprofen)
  • Severe pain: NSAIDs plus opioid combination (e.g., ibuprofen with oxycodone)
  • Consider fixed interval dosing rather than as-needed (PRN) for better pain control 1, 2

Diagnostic Approach

1. Differentiate primary otalgia (pain originating from the ear) from secondary otalgia (referred pain) 3, 4

   • Primary otalgia: Abnormal ear examination findings
   • Secondary otalgia: Normal ear examination with pain referred from elsewhere

2. Key examination elements:

   • Inspect external ear and periauricular region for redness, swelling, discharge
   • Otoscopic examination to visualize ear canal and tympanic membrane
   • Assess for tympanic membrane integrity, perforation, or tympanostomy tubes 1
   • Check for obstructed ear canal requiring aural toilet 2

Management Algorithm for Common Causes

1. Acute Otitis Externa (AOE)

• First-line treatment: Topical antibiotic preparations 1, 2

  • For intact tympanic membrane: Any approved topical preparation
  • For perforated tympanic membrane or tubes: Non-ototoxic preparations only (e.g., fluoroquinolones) 1

• Proper administration technique:

  • Position patient with affected ear upward
  • Fill ear canal completely with drops
  • Use gentle to-and-fro movement of pinna or tragal pumping 2

• If ear canal is edematous/obstructed:

  • Perform aural toilet to remove debris
  • Consider placing a wick (compressed cellulose or ribbon gauze) 1, 2

• Follow-up recommendations:

  • Reassess if no improvement within 48-72 hours
  • Complete treatment course if improving 1

2. Acute Otitis Media (AOM)

• Treatment options:
  • Mild to moderate cases: Consider watchful waiting with adequate analgesia 1
  • More severe cases: Oral antibiotics
  • If tympanic membrane perforation with drainage: Topical antibiotics 1, 2

3. Secondary Otalgia

• Common causes to evaluate:
  • Temporomandibular joint dysfunction
  • Dental infections
  • Pharyngitis
  • Cervical spine arthritis 3, 4

Special Considerations

High-Risk Patients

• Consider further evaluation for patients with:
  • Age >50 years
  • Smoking history
  • Alcohol use
  • Diabetes mellitus
  • Immunocompromised status 1, 3, 4

Red Flags Requiring Urgent Attention

• Severe pain unresponsive to appropriate analgesics
• Extension of infection outside ear canal
• Facial nerve paralysis
• Vertigo with hearing loss
• Signs of systemic illness 1

Follow-up Recommendations

• Reassess within 48-72 hours if:

  • No clinical improvement
  • Symptoms worsen
  • New symptoms develop 1

• Consider additional interventions if no improvement:

  • Reassess diagnosis
  • Ensure proper medication administration
  • Consider imaging or specialist referral for persistent symptoms 1, 4

Common Pitfalls to Avoid

1. Delaying pain management while waiting for diagnosis
2. Using ototoxic drops in patients with perforated tympanic membranes or tubes
3. Missing secondary causes of ear pain in adults (more common than primary causes)
4. Failing to recognize serious conditions presenting with ear pain as the only symptom (e.g., temporal arteritis, malignancies)
5. Inadequate follow-up for patients not showing improvement within 48-72 hours 1, 3